An atraumatic turf toe in an elite soccer player--a stress related phenomenon?

Plantar plate injuries to the hallux in elite athlete could potentially be career threatening. Reports in the literature are invariably linked to a significant traumatic episode. The occurrence of an atraumatic severe plantar plate injury in the presence of a bipartite sesamoid may suggest a stress related phenomenon. We present a case in an elite soccer player who was treated surgically and returned to top-level competition. The case is reported in detail and differences to other reports in the literature discussed.

Complex dislocation with double sesamoid entrapment of the interphalangeal joint of the hallux

A 23-year-old soccer player presented with a traumatic complex dislocation of the interphalangeal joint of the hallux with intraarticular entrapment of 2 sesamoid bones. Successful closed reduction was undertaken with excellent recovery of toe function.

Absence of the medial sesamoid bone associated with metatarsophalangeal pain

Pain at the first metatarsophalangeal (MTP) joint can result from inflammation, chondromalacia, flexor hallucis brevis tendinitis, osteochondritis dessecans, fracture of a sesamoid bone, avascular necrosis of sesamoids, inflamed bursae, intractable keratoses, infection, sesamoiditis, gout arthropathy, and rheumatoid arthritis. Congenital absence of a sesamoid bone is extremely rare. We present a 17-year-old male patient with pain at the plantar aspect of the right MTP joint associated with congenital absence of the medial sesamoid. There was tenderness and the range of motion was minimally restricted. He described the pain as necessitating changes in his social life. On radiographs, the medial hallucial sesamoid was absent on the right side. The MTP joint was also evaluated using magnetic resonance imaging (MRI). A metatarsal pad was prescribed and the patient was satisfied with the treatment at the 2 months follow-up period. MRI revealed no pathological tissue at the medial sesamoid site. Hallucial sesamoids absorb pressure, reduce friction, protect the tendons, act like a fulcrum to increase the mechanical force of the tendons, and provide a dynamic function to the great toe by elevating first metatarsal head. Congenital absence of these bones is very rare but we must consider it in a patient with MTP joint pain.

Effect of metatarsophalangeal joint position on the reliability of the tangential sesamoid view in determining sesamoid position

BACKGROUND

Lateral displacement of the sesamoids of the first toe relative to the metatarsal head is a common finding in hallux valgus deformity. Several methods have been described for quantifying the amount of subluxation from anteroposterior radiographs but a tangential sesamoid radiograph has been determined to be the best view to evaluate sesamoid displacement.

METHOD

We evaluated the sesamoid position at different angles of the first metatarsophalangeal (MTP) joint to determine the effect of first MTP joint dorsiflexion on sesamoid position when tangential sesamoid view radiographs are made. Sesamoid positions of 22 feet with hallux valgus were graded from the short axis computed tomography (CT) images obtained with the MTP joint in 0, 35, and 70 degrees of dorsiflexion.

RESULTS

Approximation of the sesamoids to reduction was apparent as dorsiflexion of the first MTP joint increased.

CONCLUSION

Different dorsiflexion degrees of the first MTP joint when tangential sesamoid radiographs are made modulate the position of the sesamoids and may lead to misclassification on grading.

The effect of sesamoid mobilization, flexor hallucis strengthening, and gait training on reducing pain and restoring function in individuals with hallux limitus: a clinical trial

STUDY DESIGN

Clinical trial.

OBJECTIVE

To determine the effect of 2 conservative intervention approaches for functional hallux limitus.

BACKGROUND

Metatarsophalangeal joint (MPJ) sprains are common and can result in long-term sequelae such as persistent pain and loss of range of motion (ROM) secondary to bony proliferation and articular degeneration. It is important to determine the most effective intervention for functional hallux limitus to decrease pain and restore function.

METHODS AND MEASURES

Twenty individuals with first MPJ pain, loss of motion, and weakness participated in the study. All patients received whirlpool, ultrasound, first MPJ mobilizations, calf and hamstring stretching, marble pick-up exercise, cold packs, and electrical stimulation. Ten of the 20 patients (experimental group) also received sesamoid mobilizations, flexor hallucis strengthening exercises, and gait training. Treatment was provided 3 times a week for 4 weeks. Measurements of first MPJ extension ROM, flexor hallucis strength, and subjective pain level were performed on the first and last visits.

RESULTS

Following the 12 therapy sessions, the experimental group achieved significantly greater MPJ extension ROM and flexor hallucis strength and had significantly lower pain levels as compared to the control group (P<.001).

CONCLUSIONS

These results suggest that sesamoid mobilization, flexor hallucis strengthening, and gait training should be included in the plan of care when treating an individual with functional hallux limitus.

Keratotic disorders of the plantar skin

Keratotic lesions on the plantar aspect of the foot develop beneath an osseous prominence and can result in substantial disability. This occurs because, during normal gait, the metatarsal head area is subjected to more prolonged stress than any other area on the plantar aspect of the foot. In the treatment of this disorder, it is imperative to establish the etiology, among many possibilities, and then address the specific pathology accordingly.

Lateral shifting of the first metatarsal head in hallux valgus surgery: effect on sesamoid reduction

Thirty feet with hallux valgus (HV) having grade 2 and 3 sesamoid stations on AP radiographs were examined after Lindgren-Turan oblique distal metatarsal osteotomy with a minimum follow-up of 12 months. Adductor tendon release from the lateral sesamoid was not performed to determine the isolated effect of distal metatarsal osteotomy on metatarsosesamoidal reduction. Of the 30 feet, 20 (67%) had reduced and 10 (33%) unreduced sesamoids at the follow-up. Ultimately, distal metatarsal osteotomy (DMO) with lateral shifting of the first metatarsal head more than 7.2 mm was found to reduce the sesamoids in the great majority of the cases (95% CI 7.243-9.757). Sesamoid release is redundant for metatarsosesamoidal reduction if sufficient lateral shift of the first metatarsal head over the sesamoids is accomplished.

Treatment of fabella syndrome with manual therapy: a case report

STUDY DESIGN

Clinical case report.

OBJECTIVES

To educate clinicians about fabella syndrome as a possible cause for posterolateral knee pain and dysfunction. Also to describe a physical therapy intervention strategy for posterolateral knee pain secondary to hypomobility or malposition of a fabella.

BACKGROUND

A 44-year-old, physically fit, Caucasian male with a 10-year history of left posterolateral knee pain and functional limitations during athletic activities, walking, and activities of daily living presented for evaluation and treatment. He had previously experienced relief of symptoms after experimenting with a mechanical maneuver administered by his wife.

METHODS AND MEASURES

A thorough examination for strength, range of motion, and accessory motions was performed. A fabella was palpable in the lateral head of the gastrocnemius muscle and a provisional diagnosis of fabella syndrome was made. While in a prone position, the patient received soft tissue mobilization of the lateral gastrocnemius, followed by medial, lateral, and inferior glides of the fabella.

RESULTS

The patient reported an immediate reduction in posterolateral knee pain and demonstrated a 30 degrees increase in active knee flexion.

CONCLUSIONS

Physical therapists may be unaware that fabella syndrome is a possible source of posterolateral knee pain and dysfunction. This simple manual therapy intervention was effective in reducing symptoms of pain and increasing tolerance for activities involving knee flexion, extension, and rotation. Physical therapists may wish to add this diagnosis and the corresponding examination and intervention techniques to their management strategy for patients with fabella syndrome.

A comparison of ultra-high-molecular weight polyethylene cable and stainless steel wire using two fixation techniques for repair of equine midbody sesamoid fractures: an in vitro biomechanical study

OBJECTIVE

To compare the monotonic tensile and fatigue strength of 16-gauge stainless steel wire (SSW) to ultra-high-molecular weight polyethylene (UHMWPE) cable using a transfixed cerclage technique in an in vitro midbody sesamoid osteotomy model. Endoscopic modifications to Martins transfixed cerclage technique were developed. A new suture technique of fixation was compared with the transfixed cerclage technique by measuring gap formation after cyclic testing.

STUDY DESIGN

An in vitro biomechanical paired equine cadaver limb study.

SAMPLE POPULATION

Twenty-one paired cadaveric adult equine forelimbs.

METHODS

Uniaxial medial midbody sesamoid osteotomies were created in paired adult equine forelimbs. Monotonic tensile strength was measured on 10 forelimbs repaired by a transfixed cerclage technique using wire or cable. Fatigue testing to failure was performed on 4 forelimbs repaired using the transfixed cerclage technique by cycling the limbs between 500 N and 2,000 N. The limbs were initially repaired with wire, cycled until the wire broke, then repaired with cable and cycled again to failure. Fatigue testing for gap displacement was performed on 8 limbs repaired with either the transfixed cerclage technique or the suture technique. Limbs were cycled between 500 N and 2,000 N for 10,000 cycles. The limbs were repaired with wire initially, tested, and then repaired with cable and tested again. Twenty-two limbs were used for mechanical testing. The remaining limbs (20) were used to develop and practice the endoscopic transfixed cerclage (10 limbs) and suture (10 limbs) techniques.

RESULTS

Ultimate tensile strength (UTS) of UHMWPE cable constructs was 34% greater than the UTS of SSW constructs. Fatigue strength was 2 to 20 times greater for UHMWPE cable constructs than SSW constructs. Separation of fragments was 153% less for limbs repaired by the suture technique compared with those repaired by the transfixed cerclage technique.

CONCLUSIONS

UHMWPE cable shows promise for this clinical application because of its greater tensile and fatigue strength. The newly described suture technique significantly reduced gap formation compared with the transfixed cerclage technique. Osteotomy gap formation occurred early in cycling, suggesting that rigid support in the form of a cast may be needed during the early postoperative period for wiring techniques.

CLINICAL RELEVANCE

Clinical testing of UHMWPE cable should eliminate problems of wire breakage seen with SSW. The endoscopic transfixed cerclage technique can be used by surgeons familiar with arthroscopic surgery. However, the suture technique needs to be tested in vivo to determine whether there is a clinical advantage compared with the transfixed cerclage technique.

New radiographic analysis of sesamoid rotation in hallux valgus: comparison with conventional evaluation methods

The position of the hallucal sesamoids needs to be included in evaluation of hallux valgus. In order to quantify the rotational position of the hallucal sesamoids, a new weightbearing tangential radiograph was established by means of a specially designed tangential positioning device. This device has a depression, and a tangential radiograph is taken with the metatarsophalangeal joint at 45 degrees dorsiflexion. A lead marker plate is placed on the depression to show the horizontal plane, and the sesamoid rotation angle (SRA) is measured. The SRA is the angle between the tangential line of the most inferior aspect of the medial-lateral sesamoids and the lead marker line. The SRA was compared with values of the four-grade scale and seven-position scale which were measured from the antero-posterior view, with respect to the hallux valgus angle (HVA), by means of conventional methods. Measurements were made of 58 feet in 29 patients with hallux valgus and 64 feet in 32 normal subjects. The SRA showed the highest correlation among the three parameters (r=0.817). Some cases had a disparity regarding the position of the sesamoids between the tangential view and the AP view due to misclassification on the AP view. We conclude that the scale of position of the sesamoid on the AP view is not valid in some cases, whereas the SRA is useful for assessing quantitatively the rotational position of the hallucal sesamoids in cases of hallux valgus.

The passive axial compression (PAC) test: a new adjunctive provocative maneuver for the clinical diagnosis of hallucal sesamoiditis

The authors describe a previously unreported adjunctive passive provocative maneuver that has been found to clinically reproduce the intensity of symptoms in patients diagnosed with disorders of the sesamoids. This test is useful for the initial diagnosis as well as monitoring response to treatment.

The force and contact stress on the navicular bone during trot locomotion in sound horses and horses with navicular disease

Mechanical overload due to poor conformation or shoeing has been suggested to contribute to the development of navicular disease. While studies have determined the compressive force exerted on the navicular bone in normal horses, this has not been reported for horses with navicular disease. Also, the force has not been converted to stress by correction for contact area. In this study we developed a technique for the determination of the contact area between the deep digital flexor tendon and the navicular bone in vivo, and used a forceplate system to determine the force and stress on the bone at trot in 6 normal and eight diseased horses. The mean +/- s.d. peak force and peak stress were 5.62+/-1.45 N/kg and 2.74+/-0.76 MPa for the normal group and 6.97+/-1.50 N/kg and 3.07+/-0.55 MPa for the navicular disease group. The peak force and peak stress were similar for both groups but the force and stress in the horses with navicular disease were approximately double control group values early in the stance phase. This was due to a higher force in the deep digital flexor tendon, which was attributed to a contraction of the deep digital flexor muscle in early stance in an attempt to unload the heels.

Sesamoid problems

The understanding of the pathology and treatment of hallux sesamoid disorders has improved considerably over the last few decades. It is interesting to speculate what further improvements are on the horizon. Newer imaging methods and possibly an increased use of small joint arthroscopy may make it possible to better diagnose and treat conditions of these two small bones and to develop better biologic and artificial methods of surface replacement. In the meantime clinicians should only excise sesamoids if it is really essential.

Scarf osteotomy for correction of hallux valgus. Surgical technique and results as compared to distal chevron osteotomy

With the Scarf osteotomy, a good correction of moderate hallux valgus can be obtained, comparable to the distal or proximal Chevron or crecentic osteotomy. Correction of the IMA averages between 5 degrees to 6 degrees. When used in combination with an adductor release and proximal phalangeal osteotomy, the indication can be extended to severe hallux valgus deformities as long as there is no arthrosis at the MTP joint. The Scarf osteotomy, however, is certainly a more extensive surgical procedure, with a longer learning curve than a distal Chevron osteotomy. With more than 1000 Scarf procedures performed, the author has not encountered one delayed union, even in osteoporotic bone, or an avascular necrosis. In two cases a stress fracture was encountered in the first 3 months after surgery, but these healed uneventfully with partial weight bearing for 5 weeks.

In vitro biomechanical properties of 2 compression fixation methods for midbody proximal sesamoid bone fractures in horses

OBJECTIVE

To evaluate 2 methods of midbody proximal sesamoid bone repair--fixation by a screw placed in lag fashion and circumferential wire fixation--by comparing yield load and the adjacent soft-tissue strain during monotonic loading.

STUDY DESIGN

Experimental study.

SAMPLE POPULATION

10 paired equine cadaver forelimbs from race-trained horses.

METHODS

A transverse midbody osteotomy of the medial proximal sesamoid bone (PSB) was created. The osteotomy was repaired with a 4.5-mm cortex bone screw placed in lag fashion or a 1.25-mm circumferential wire. The limbs were instrumented with differential variable reluctance transducers placed in the suspensory apparatus and distal sesamoidean ligaments. The limbs were tested in axial compression in a single cycle until failure.

RESULTS

The cortex bone screw repairs had a mean yield load of 2,908.2 N; 1 limb did not fail when tested to 5,000 N. All circumferential wire repairs failed with a mean yield load of 3,406.3 N. There was no statistical difference in mean yield load between the 2 repair methods. The maximum strain generated in the soft tissues attached to the proximal sesamoid bones was not significantly different between repair groups.

CONCLUSIONS

All repaired limbs were able to withstand loads equal to those reportedly applied to the suspensory apparatus in vivo during walking.

CLINICAL RELEVANCE

Each repair technique should have adequate yield strength for repair of midbody fractures of the PSB immediately after surgery.

Biomechanics of the first ray. Part II: Metatarsus primus varus as a cause of hypermobility. A three-dimensional kinematic analysis in a cadaver model

Variation in functional stability of the first metatarsocuneiform joint was analyzed between transverse plane deviated (adducted) and corrected first metatarsal positions in a closed kinetic chain model. Six fresh frozen cadaver specimens with intact ankles and feet were fitted with a custom fabricated titanium metatarsal jig, which allowed for manipulation of the first metatarsal in the transverse plane. Specimens were mounted into a custom-made acrylic load frame and axially loaded to 400 N. Radiowave three-dimensional tracking transducers were attached to the following osseous segments: first metatarsal head and base, medial cuneiform, and second metatarsal. A dorsally directed load was applied to the first metatarsal segment and resultant movements were measured. Repeated testing was performed on a transverse deviated and corrected first metatarsal positions with the hallux plantargrade and maximally dorsiflexed to engage the windlass mechanism. With the windlass mechanism engaged and first metatarsal corrected, a 26% increase in first ray plantarflexion occurred from a deviated to a corrected first metatarsal position (p < or = .05). This suggests that the windlass mechanism is more efficient when the first metatarsal, sesamoid apparatus, and hallux position are properly aligned with the orientation of the plantar aponeurosis. Clinically, this may explain the correlation of first ray hypermobility with the progression of bunion severity. Our study validates the earlier work of Hicks and adds additional insight into the functional stability in the medial column of the foot.

Treatment of rupture of suspensory ligament and superficial flexor tendon in a bull

Rupture of the suspensory ligament at the insertions on the proximal sesamoid bones, and of the superficial flexor tendon of the left fore limb, occurred in an adult Angus bull as a result of fighting. There was severe hyperextension of the metacarpophalangeal (MCP) joint with the dewclaws almost touching the ground. Radiographs revealed severe hyperextension of the MCP joint with the sesamoid bones aligned directly distal to the metacarpus. Initially, a full length fiberglass cast was applied with the limb partially flexed within the cast and the heels elevated. The cast was replaced twice. The cast was removed after 136 days and the bull was bearing full weight on the limb. Prolonged immobilisation of the limb produced new bone in the area (a normal response in cattle) to cause ankylosis of the traumatized MCP joint and partial ankylosis of the carpus. The bull was being used for pasture breeding one year after the injury.

[Biomechanical investigation of the sesamoid bones of the hallux]

Extensive research has been done on disorders of the sesamoid bone of the hallux. However, reports on the mechanism of the disorder are few and a comprehensive assessment of the biomechanical role played by the sesamoid bone has not been done. In an effort to elucidate the role of the sesamoid bone, we have developed a force sensor which utilizes the capacitance method, and evaluated the biomechanical aspects of fatigue fracture associated with it. Three frozen stored human limbs were thawed at room temperature. The force between the sesamoid bone and the first metatarsal head was measured using force sensors which were placed on the bilateral sesamoid bones. Measurements were also taken at varying loads and angles of dorsiflexion of the MTP (metatarsophalangeal) joint of the hallux from 0 degrees to 60 degrees at increments of 10 degrees. This was done by applying weights ranging from 0 to 4 kg to the first metatarsal head at increments of 1 kg. Load and angle of dorsiflexion of the MTP joint were found to be correlated with the degree of compression force between the hallux sesamoid bone and the first metatarsal head; the load applied affected the force to a greater extent than did the angle. Dorsiflexion of the MTP joint of the hallux had no effect on the amount of compression force between the medial and lateral sesamoid bones, but the increase in compression force became pronounced when the angle of dorsiflexion exceeded 30 degrees.

Symptomatic bipartite sesamoids

The great toe sesamoids have been well reported in the literature, in every aspect. Much has been written about the normal anatomic variation of partite metatarsophalangeal sesamoids. It is the purpose of this article to present a theory explaining the common occurrence of a symptomatic partite sesamoid. The authors believe there is a high rate of occurrence of symptomatic partite sesamoids, especially when associated with hallux abducto valgus. Presented is information concerning the internal and external structural components of a bipartite metatarsal sesamoidal joint, which may inherently lead it to symptomatology.

Pathophysiology of navicular syndrome

Navicular syndrome is a degenerative disorder of the distal half of the flexor surface of the proximal sesamoid bone that is predisposed by faulty foot conformation. In horses that become symptomatic, the faulty conformation results in sustained application of nonphysiologic pressure by the deep digital flexor tendon against the flexor cortex of the bone. This force stimulates an intense bone remodeling response in order to attenuate the pressure. An unfortunate sequela of this response is active hyperemia and edema formation in the medullary cavity of the bone. The edema is organized by fibrous tissue resulting in venous entrapment, venous hypertension, vascular bone pain, and the onset of clinical signs.

Orthotic treatment of sesamoid pain

The cause of pain and tenderness beneath the first metatarsal in an athlete is often very difficult to determine. When the symptoms originate from the sesamoid bone, exact diagnosis of the pathologic process may not be necessary in order to institute effective treatment. In this retrospective study, 8 of 10 athletes with this problem were successfully treated with custom-fitted orthoses which relieve sesamoid pain. The major benefit of this method of treatment is that it enables an athlete to continue participation without loss of valuable practice and competition time.

Sesamoid foot problems in the athlete

Problems of the sesamoid bones of the metatarsophalangeal joint of the great toe are critical in maintaining full ability to compete or to engage in recreation--in athletes of any age. The sesamoids are subject to the same post-traumatic, acute, and chronic changes as any other bone. These unique and deceptively important injuries demand a high index of suspicion, a thorough diagnostic effort, and a guided long-range treatment program, including follow-up to normalized athletics, particularly in the running-based sports.

The simple bunion: anatomy at the metatarsophalangeal joint of the great toe

The pathomechanics for the development of the hallux valgus deformity takes place at the first metatarsophalangeal joint--the sesamoid complex. The sesamoid complex consists of seven muscles, eight ligaments, and two sesamoid bones. When the first metatarsal escapes the complex and drifts medially, the sesamoids remain twisted in situ, several of the ligaments "fail," and others contract. The authors propose reduction of the metatarsus primus varus by first metatarsal osteotomy and appropriate ligament releases and plications to restore alignment. A detailed understanding of the pathomechanics is essential for proper interpretation of the problems and anticipated lasting surgeries.

The sesamoids of the hallux

The seemingly innocuous tiny sesamoids play an important role in the function and pathomechanics of the hallux. The recent active participation of people of all ages in jogging and long-distance running, activities introducing repetitive stressful forces on the forefoot, induces sesamoiditis. Bones normally asymptomatic, such as the sesamoids, require renewed interest in embryology, anatomy, congenital variations, infection, osteochondritis, trauma and effective treatment.

Amputation of the great toe

Four patients who had undergone reimplantation of the great toe to create a thumb were studied. The follow-up period ranged from 29 to 62 months. In all cases, the great toe was disarticulated at the metatarsophalangeal joint. The patients felt their feet functioned at approximately 85% of normal, and none had any significant complaint of metatarsalgia. The one patient who participated in sports after the surgery noted that it was difficult to "push off" moving away from the involved foot. X-ray examination demonstrated retraction of the sesamoids, which accounted for the increased plantar flexion of the first metatarsal shaft. The second metatarsophalanageal joint drifted into varus an average of 8 degrees. The Harris mat demonstrated that there was an increase in weightbearing beneath the second and third metatarsal heads. It appears as though, on the basis of this study, the loss of the great toe in this manner does not significantly affect the normal everyday function of an individual's foot.